Who is responsible for people's health?

Dr Giridhara R Babu
AA
Are you healthy? Hold on to your answer till we unravel what health means. Being in
impeccable health means that you don't suffer from any physical illness in any form and,
you have flawless state of mental and societal contentment. Now, are you healthy?
If your answer is no, don't be surprised, as you are among the majority. Momentarily, it might
appear that being healthy might be a utopian resolve, rarely ever attainable by any individual in
their lifespan. Luckily, it may not be that hard too, if concerted actions are taken by individual
and few departments.
To understand these concerted actions, it is important to understand factors regulating health.
Dahlgren and Whitehead in 1991 described numerous factors at multiple levels ranging from
societal to individuals. The first layer of health determinants comprise of modifiable factors
including personal behaviour and lifestyle that can promote or rescind health. For example,
smoking is modifiable behaviour that can be stopped to promote health at individual level.
The next layer comprises of social and community factors, which can either support or upset the
health. For example, smoking behaviour can be either started or stopped by the kind of friends
one has or due to the family or community norms. The final level contains essential factors such
as agricultural production, education, work environment, living and working conditions,
unemployment, water and sanitation, health care services and housing. Using same analogy,
smoking policies about tobacco production and consumption affect overall smoking prevalence.
Let us examine another example. In order to walk and be disease-free, at individual level, you
have to have a resolve, decide and start walking by attempting every day. At the community
level, it helps to have friends who motivate walking and family which has adopted walking as a
habit. Structural level factors include whether you are able to cross the road without fear of being
knocked down by rash drivers, how accessible are walking lanes, parks or gyms in order to
continue your walking routine.
So, whose responsibility is to fix the health of India's citizens? Undeniably, the first set of actions
is at the individual level. These can be achieved through constant education and awareness
among the masses. The effort in promoting yoga by Prime Minister Narendra Modi is a best first
step forward. The awareness needs expansion with several collaborative actions embracing
religious and local cultural beliefs, enhancing healthy traditions, incorporating promotion of
healthy behaviour through school curriculum and involving women's self help groups as change
agents.
Fixing responsibility
However, the biggest problem is that several programmes are evasive in fixing responsibility for
health only at individual level with inertia at other levels of determinants. To redress the
longstanding inaction, laudable effort of the current administration is the Swachh Bharat Abhiyan
(SBA) aiming to tackle sanitation menace. However, barring these two initiatives, no other

department either at Centre or local levels has addressed any other determinant at any other level.
One would understand from the discussion so far that department of health per se has limited
control over your health. At the most, it provides sickness relief and some health promotion
activities such as immunization. Yet, it has become an unfair tradition and custom to blame the
health department for all the woes the country has. The way forward for healthy India should
involve several other departments and community actions. For India's health to improve, all
determinants of health should be addressed at every level. The government can create an
overarching mission to address all the health determinants.
A simplistic tool such as ranking the blocks/districts based on the level of accomplishments in
social determinants can guide future course of action. Simple yet effective solutions such as
rewarding the local bodies through extra grants and recognition can imbibe pride in the villages
and can ensue healthy competition. The progress can be monitored as performance indicators of
administrators at block and district level. The chief minister can spearhead the mission with the
accountability set at the level of development commissioner.
(The writer is Additional Professor, IIPH Bengaluru, a unit of Public Health Foundation of
India)
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